<%@ include file="/common/taglibs.jsp" %>
<html>
	<head>
		<title></title>
		<link rel="/grouper-webapp/styles/wufoo/theme.css" />
		<link rel="/grouper-webapp/styles/wufoo/structure.css" />
		<link rel="/grouper-webapp/styles/wufoo/form.css" />
		<style type="text/css">
			form.grouper ul {
				list-style: none;
			}
			
			form.grouper ul li {
				padding-bottom: 10px;
			}
			
			form.grouper ul li span {
				
			}
			
			
		</style>
	</head>
	<body>
		<div id="container">
<form:form cssClass="grouper" commandName="profile" action="" method="post">
<div class="info">
<h2>Membership Profile Information</h2>
</div>
<ul>
	<li>
		<label class="desc">Name</label>
		<span>
			<form:input path="firstName" cssClass="field text" size="14" /><label>First</label>
		</span>
		<span>
			<form:input path="lastName" cssClass="field text" size="14"/><label>Last</label>
		</span>
		<span>
		</span>
	</li>


	<li>
		<label class="desc">Title<span class="req">*</span></label>
		<div><form:input path="title" cssClass="field text medium" /></div>
	</li>
	<li>
		<label class="desc">Organization Name<span class="req">*</span></label>
		<div>
			<input name="companyName" class="field text medium" type="text" maxlength="255" value="Example text." />
		</div>
	</li>

	<li><label class="desc">FTZ #</label>
		<div>
			<form:input path="ftzNumber" cssClass="field text medium" />
		</div>
	</li>

	<li>
		<label class="desc">Address</label>
		<div class="column"><span class="full">
			<form:input path="primaryAddress.street1" cssClass="field text addr" /><label>Street Address</label></span>
			<span class="full">
				<form:input path="primaryAddress.street2" cssClass="field text addr" />
				<label>Address Line 2</label>
			</span>
			<span class="left">
				<form:input path="primaryAddress.city" cssClass="field text addr" />
				<label>City</label> 
			</span> 
			<span class="right"> 
				<form:input path="primaryAddress.state" cssClass="field text addr" />
				<label>State / Province / Region</label> 
			</span> 
			<span class="left"> 
				<form:input path="primaryAddress.zipCode" cssClass="field text addr" />
				<label>Postal / Zip Code</label> </span> <span class="right">
				<form:select cssClass="field select addr" items="${countries }" path="primaryAddress.country" /><label>Country</label> </span></div>
	</li>

	<li><label class="desc">Referred by</label>
	<div><form:input path="referredBy" cssClass="field text medium" /></div>
	</li>
	<li><label class="desc">Industry</label>
	<div><form:input path="industry" cssClass="field text medium" /></div>
	</li>
	<li>
		<input type="submit" value="Next &raquo;"/>
	</li>

</ul>
</form:form>
</div>
</body>
</html>